Discussion of hormone replacement therapy between physicians and their patients

The role of unconscious bias in surgical safety and outcomes

Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients' sociocultural context promotes just, equitable, and compassionate care to all patients.

Racial differences in follow-up of abnormal mammography findings among economically disadvantaged women

BACKGROUND

In the United States, and particularly in South Carolina, African-American women suffer disproportionately higher mortality rates from breast cancer than European-American women. The timeliness of patient adherence to the follow-up of mammographic abnormalities may influence prognosis and survival. The objective of the current investigation was to examine racial differences in the completion and completion time of a diagnostic workup after the finding of a suspicious breast abnormality.

METHODS

Study participants of the Best Chance Network, a statewide service program that provides free mammography screening to economically disadvantaged and medically underserved women, were included in the study. Racial differences in tumor characteristics and adherence to recommended workup were tested using chi-square tests and t tests. Logistic and Cox regression modeling was used to assess the relation between workup completion and other factors among African-American women and European-American women.

RESULTS

Completion of the workup was associated with the number of previous procedures and income, and no significant differences were noted by race. The amount of time to completion of the workup was influenced by previous procedures, income, and race. After accounting for completion time, African-American women were 12% less likely than European-American women to complete the recommended workup (hazard ratio, 0.88; P=.01).

CONCLUSIONS

The results from this study established a racial disparity in the time to completion of a diagnostic workup among Best Chance Network participants. These findings highlight the importance of understanding the factors associated with delays in and adherence to completing the recommended workup when breast abnormalities are detected in mammograms.

Hormone therapy, dilemmas, medical decisions

The decision for women to go on hormone therapy (HT) remains controversial. An historical oscillation of beliefs exists related in part to expectations of the medicinal value of HT over longer-term use beyond the initial peri-menonpausal period. Studies thought to resolve issues surrounding the efficacy of HT were perhaps overstated as confusion still permeates the decision making with regard to HT. Overzealous advertising and exaggerated understanding of the results (negative or positive) undermine patient and physician decision making. There remains no magic bullet with regard to HT. What remains is still the possibility of HT longer-term efficacy on diverse end organ systems with pockets of clinical and scientific ambiguity while working to engender reasonable expectations.

Menopausal Symptom Management and Prevention Counseling after the Women's Health Initiative among Women Seen in an Internal Medicine Practice

OBJECTIVE

To describe the management of menopausal symptoms and the prevalence of prevention counseling among women who stopped hormone therapy (HT) after publication of the initial findings of the Women's Health Initiative.

METHODS

Telephone survey between July and September 2003 of 142 women 50 years and older, randomly selected from a large academic primary care practice, who stopped taking HT after the WHI publication, July 9, 2002 (66% response rate).

RESULTS

Among 142 women, the median age was 60 years, 63% were white, 52% had at least a college degree, and 60% were taking estrogen and progestin as of July 9, 2002. The majority (82%, n = 117) who stopped HT suffered some menopausal symptom: 25 restarted HT, 13 received another prescription medication, and 56 tried at least one complementary and alternative medicine. Women most commonly used soy (n = 40) or black cohosh (n = 25) for their symptoms, although less than one third of women found either of these treatments effective. Only 49% (57 of 117) of women with symptoms visited a doctor for their symptom. Few women reported receiving counseling about prevention topics after the WHI, such as risk of osteoporosis (34%), risk of heart disease (26%), diet (41%), and exercise (45%).

CONCLUSIONS

Most women who stopped HT after the WHI experienced some menopausal symptoms. Few women found commonly used alternative medicines effective, and few received other prescription medications. Counseling about osteoporosis and heart disease risk was infrequent after the WHI. Future studies should focus on finding safe and effective therapies for menopausal symptoms.

Is hospital service associated with racial and ethnic disparities in experiences with hospital care?

PURPOSE

Little is known about the influence of processes of hospital care on racial and ethnic differences in experiences with hospital care.

SUBJECTS AND METHODS

To determine whether patient experiences differed by race and ethnicity and whether these differences were associated with hospital care characteristics, we analyzed survey and hospital administrative data from 2664 adult patients after hospitalization at an urban teaching hospital during 1998-1999. We assessed the association of patient race and ethnicity with reporting problems in multiple dimensions of patient experience, using logistic regression to adjust for sex, age, self-reported health status, insurance status, income, route of hospital admission, and hospital service. We then stratified adjusted analyses by hospital service.

RESULTS

After adjustment for demographic and hospital characteristics, black (odds ratio (OR): 1.8; 95% confidence interval [CI]: 1.3-2.6) and Latino (OR: 2.0; 95% CI: 1.3-3.0) patients reported more problems with respect for their preferences compared to whites. Blacks reported more problems with respect for their preferences (OR: 1.7; 95% CI: 1.0-3.0) among patients discharged from surgical services, and Latinos reported more problems with respect for their preferences (OR:3.6; CI: 1.6-8.2) among patients discharged from obstetrical services when compared to whites. Patient experiences did not significantly differ by race among patients discharged from medical services.

CONCLUSIONS

We found significant racial and ethnic differences in patients' experiences with hospital care, particularly in respect for patient preferences. Our findings suggest physicians and hospital staff should strive to understand and address the expectations of black and Latino patients, particularly those who are hospitalized for surgical or obstetrical issues.

Why do providers contribute to disparities and what can be done about it?

This paper applies social cognition research to understanding and ameliorating the provider contribution to racial/ethnic disparities in health care. We discuss how fundamental cognitive mechanisms such as automatic, unconscious processes (e.g., stereotyping) can help explain provider bias. Even well-intentioned providers who are motivated to be nonprejudiced may stereotype racial/ethnic minority members, particularly under conditions of that diminish cognitive capacity. These conditions-time pressure, fatigue, and information overload-are frequently found in health care settings. We conclude with implications of the social-cognitive perspective for developing interventions to reduce provider bias.

The role of trust in use of preventive services among low-income African-American women

BACKGROUND

This study explored factors that predict higher trust in primary care providers, and examined the role of patient trust on the use of preventive services for low-income African-American women.

METHODS

We conducted a cross-sectional, population-based telephone survey of 961 African-American women over age 40 in Washington, DC. Two dimensions of trust were examined: overall trust in one's regular primary care provider, and trust that the regular provider had no financial conflict of interest. Self-reported use of mammography, Pap tests, clinical breast exams, colorectal cancer screening, blood pressure, height and weight measurement, diet counseling, and depression screening, as delivered by one's primary care provider, were assessed. An index summarizing overall use of these interventions was the main outcome variable.

RESULTS

More than two-thirds of respondents reported high trust in their physician. Older respondents (>65) were more trusting of their physicians overall than were younger respondents (P < 0.01). Primary care characteristics (continuity of care, accessibility of the practice, coordination of specialty care by one's regular provider) were more strongly associated with having high trust than were sociodemographic, health status, and insurance characteristics. Higher trust was significantly associated with greater use of recommended preventive services (OR: 2.3, 95% CI: 1.3, 4.0), controlling for the effects of insurance status, primary care, and patient characteristics.

CONCLUSIONS

Trust is associated with use of recommended preventive services in low-income African-American women. Stronger patient-provider relationships, with high levels of trust, may indirectly lead to better health through adherence to recommended preventive services for low income African-American women.

Hormone therapy prescription among physicians in France and Quebec

OBJECTIVE

Our objective was to compare physician characteristics associated with high-frequency hormone therapy (HT) prescription between gynecologists and general practitioners (GPs) within and between France and Quebec, Canada.

DESIGN

A self-administered mail survey was sent to a representative sample of 2,000 physicians in France and 1,000 physicians in Quebec. High-frequency prescribers were those who reported prescribing HT to more than 70% of their postmenopausal patients. The following characteristics were included in the analysis: country, specialty, age, gender, characteristics of the practice (solo or group, private or public, rural or urban, number of patients seen daily, duration of practice, percentage of women 45 years or older), teaching or research activities, participation in education course on HT, and practice patterns relating to menopausal women (having patient education materials available, providing materials to patients, and discussing the possibility of HT).

RESULTS

The analysis covered 974 physicians in France (389 GPs and 585 gynecologists) and 452 physicians in Quebec, Canada (318 GPs and 134 gynecologists). Despite differences in health care, in both countries gynecologists were more likely to be high-frequency prescribers than were GPs, although this difference was smaller in Quebec. Canadian physicians were more likely to prescribe HT. The difference between countries was greatest among GPs. Except for nationality and practice patterns designed to provide women with information, none of the physician characteristics was associated with high-frequency prescription among GPs. Among gynecologists, only the number of patients per day and the provision of information were associated with high-frequency prescription.

CONCLUSIONS

Notwithstanding a common language, differences in the prescription pattern of HT between countries were greatest at the level of primary care than secondary care. In both countries, specialists were more likely to prescribe HT than were GPs. Implementation of clinical practice guidelines to set baseline standards in the field of menopausal health remains a challenge but will need to take into account cultural characteristics as well as level of medical care.

Physician counseling on hormone replacement therapy and bone loss: do socioeconomic and racial characteristics of women influence counseling?

BACKGROUND

Although women consider multiple issues when deciding to take hormone replacement therapy (HRT), both women's use and physician counseling about HRT are strongly associated with sociodemographic factors. As prevention of bone loss is the best established long-term benefit of HRT, we sought to determine (1) if counseling about bone loss is included in discussions of HRT and (2) if sociodemographic factors affect the preventive content of HRT counseling.

METHODS

We evaluated reports of counseling on estrogen and bone loss from 1404 women aged 40-60 who reported any counseling on HRT in the 1994 National Health Interview Survey (NHIS). We also examined the association between these reports and sociodemographic factors, adjusting for clinical history, physician specialty, and physician visits.

RESULTS

We found that 80% of the women reported counseling on the effects of estrogen on bone loss. After adjustment, high school graduates (adjusted odds ratio [AOR] 1.68, confidence interval [CI] 1.02, 2.77) and college graduates (AOR 2.45, CI 1.33, 4.52) were much more likely to be counseled than women without a high school diploma. Black women were less likely to be counseled about bone loss (AOR 0.55, CI 0.33, 0.93). Although general health and menopausal symptoms were strongly associated with counseling on HRT and bone loss, neither of the osteoporosis risk factors of low body mass index (BMI) and smoking influenced counseling.

CONCLUSIONS

Most patients who discussed HRT with their providers discussed the effects of HRT on bone loss. For those who did not, several sociodemographic factors associated with any counseling on HRT are also associated with the content of HRT counseling. Understanding and addressing counseling inequities could reduce the effect of such factors on osteoporosis assessment and treatment.

Race, quality of depression care, and recovery from major depression in a primary care setting

Racial variations in the use of effective medical care and subsequent clinical outcomes have been identified for many medical conditions. Still, it is unclear whether racial variations in care and clinical outcomes exist for depressed primary care patients. Primary care patients presenting for routine treatment were screened for major depression as part of a study to disseminate a depression treatment guideline. Primary care physicians (PCPs) were informed of their patients' depression via an electronic medical record system and asked whether they agreed with the diagnosis. Treatment patterns and depressive symptoms over the following six-months were assessed by chart review and the Hamilton Rating Scale for Depression, respectively. Over a 20-month period, 8,944 African-American and Caucasian patients aged 18-64 were approached for screening. African-Americans were less likely to agree to undergo screening than Caucasians (83% vs. 88%; P<.0001), but those doing so were more likely to report mood symptoms (26% vs. 15%; P<.001). 204 patients, including 52 African-Americans (25%), met protocol-eligibility criteria and completed a baseline interview. Baseline sociodemographic and clinical characteristics, and PCPs' agreement rate with the depression diagnosis were similar. Although PCPs were less likely to counsel their African-American than Caucasian patients for depression (P=.03), this difference resolved after adjusting for education level, employment, and insurance status and we found no other variations in the depression care provided or in clinical outcomes by race. We found little racial variation in either process measures or clinical outcomes for depression in our sample of African-American and Caucasian primary care patients.

Research on the provider contribution to race/ethnicity disparities in medical care

OBJECTIVE

Little is known about why black patients and other ethnic/racial minorities are less likely to receive the best treatments independent of clinical appropriateness, payer, and treatment site. Although both provider and patient behavior have been suggested as possible explanatory factors, the potential role of provider behavior has remained largely unexplored. Does provider behavior contribute to systematic inequities? If so, why? The purpose of this paper is to build on existing evidence to provide an integrated, coherent, and sound approach to future research on the provider contribution to race/ethnicity disparities in medical care. First, the existing evidence suggestive of a provider contribution to race/ethnicity variance in medical care is discussed. Second, a proposed causal model, based on a review of the social cognition and provider behavior literature, representing an integrated set of hypothesized mechanisms through which physician behavior may contribute to race/ethnicity disparities in care is presented.

CONCLUSION

There is sufficient evidence for the hypothesis that provider behavior contributes to race/ethnicity disparities in care to warrant further study. Although there is some evidence of support of the hypotheses that both provider beliefs about of patients and provider behavior during encounters are independently influenced by patient race/ethnicity further systematic rigorous study is needed and is proposed as a major immediate research priority. These mechanisms deserve intensive research focus as they may prove to be the most promising targets for interventions intended to ameliorate the provider contribution to disparities in care.

Racial differences in physician recommendation of hormone replacement therapy

PURPOSE

Previous studies have suggested that black women may be less likely than white women to be offered and to take hormone replacement therapy (HRT). Thus, race and other factors associated with physician recommendation of HRT that may influence women's decisions about HRT were examined.

METHODS

Data were from a baseline assessment of participants in a randomized controlled trial designed to evaluate the efficacy of a tailored decision-aid on HRT decision-making. We telephone interviewed 581 Durham women ages 45-54. The association of race and other factors with reported physician recommendation of HRT was tested using chi(2) and logistic regression analysis.

RESULTS

Overall, 45% of women surveyed reported that their physician recommended HRT; black women were significantly less likely than white women to report being advised about HRT (35% vs. 48%, respectively, P < 0.005). Additional factors associated with being recommended HRT included older age, being postmenopausal, having had a hysterectomy, having thought about the benefits of HRT, and being satisfied with information about HRT.

CONCLUSIONS

Black women are less likely than white women to receive physician recommendation of HRT. Racial differences in patient-provider communication about HRT exist and thus require greater diligence on the part of health care providers to minimize such a gap.